Healthcare Provider Details

I. General information

NPI: 1104037985
Provider Name (Legal Business Name): PETERSON COLONIAL HOMES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/24/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4723 NYGAARD ROAD
BROOKSTON MN
55711-0350
US

IV. Provider business mailing address

PO BOX 350
BROOKSTON MN
55711-0350
US

V. Phone/Fax

Practice location:
  • Phone: 218-878-0642
  • Fax: 218-878-2978
Mailing address:
  • Phone: 218-878-0642
  • Fax: 218-878-2978

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3104A0625X
TaxonomyAssisted Living Facility (Mental Illness)
License Number0021
License Number StateMN

VIII. Authorized Official

Name: DUANE MELVIN SCHRAW
Title or Position: ADMINISTRATOR
Credential:
Phone: 218-878-0642